Know Your Multiple Myeloma Treatment Options

While there is no cure for mul­tiple myeloma, the cancer can be managed successfully for years in many people. Your multiple my­eloma treatment will depend on whether you are experiencing symptoms and your overall health. In many cases, a team of doctors will work with you to determine the best treatment plan. The goals of treatment are to eliminate myeloma cells, control tumor growth, control pain, and allow you to have an active life.

Your care plan may also include treatment for symptoms and side effects, an important part of cancer care. Take time to learn about all of your treatment options, including clinical trials, and be sure to ask questions about anything that is unclear. Also, talk to you doctor about the goals of each treatment and about what you can expect while re­ceiving the treatment.

Active Surveillance for People without Symptoms
People with early-stage myeloma and no symptoms, called smoldering myeloma, may simply be closely monitored by their doctor through check-ups. This approach is called ac­tive surveillance or watchful waiting.
If symptoms appear, then active treat­ment starts.

Treatment Options for People with Symptoms
Treatment for people with symptomatic myeloma includes both treatment for the disease and support­ive therapy to improve quality of life, such as by relieving symptoms and maintaining good nutrition. Disease-directed treatment typically includes drug therapy, such as targeted therapy or chemotherapy, with or without steroids. Stem cell transplantation may also be an option. Other types of treatments, such as radiation therapy and surgery, are used in specific circumstances. Each type of treatment is described below:

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Targeted Therapies
Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treat­ment blocks the growth and spread of cancer cells while limiting damage
to healthy cells. Targeted therapy has proven in recent years to be quite suc­cessful at controlling myeloma, and researchers continue to investigate new and evolving drugs for this disease in clinical trials.

Recent studies show that not all
tumors have the same targets. To find the most effective treatment, your doctor may run tests on cancer cells to identify genes, proteins, and other factors. This helps doctors better match each person with the most effective treatment when­ever possible.

Targeted therapy has proven in recent years to be quite successful at controlling myeloma, and researchers
continue to investigate new and evolving drugs for this
disease in clinical trials.

Lenalidomide (Revlimid), pomalid­omide (Pomalyst), and thalidomide (Synovir, Thalomid) are drugs that stop the growth of myeloma cells in the bone marrow. These drugs strengthen the im­mune cells to attack cancer cells. They starve the cancer cells by blocking
new blood vessel formation, a process called angiogenesis.

Bortezomib (Velcade) and carfilzomib (Kyprolis) are classified as proteasome inhibitors. They target
specific enzymes called proteasomes that digest proteins in the cells. Because myeloma cells produce a lot of proteins, they are particularly vulner­able to this type of drug.

Panobinostat (Farydak) is an inhibi­tor of the enzyme Histone Deacetylase (HDAC). These enzymes help keep the DNA tightly coiled, while panobinostat helps uncoil the DNA and activate genes that arrest the growth of cancer cells.

Thalidomide, lenalidomide, and bort­ezomib may be used to treat those who are newly diagnosed, while lenalidomide, pomalidomide, bortezomib, carfilzomib, and panobinostat are effective for treat­ing recurrent myeloma. Targeted therapies may also be used in combination with chemotherapy or steroid medications, as certain combinations of drugs can some­times have a better effect than a single drug. For example, the drugs lenalido­mide, bortezomib, and dexamethasone, as well as bortezomib, cyclophospha­mide, and dexamethasone, are offered in combination.

Clinical trials are underway to
explore whether the combination of lenalidomide, bortezomib, and dexa­methasone alone may be as effective
as lenalidomide, bortezomib, and
dexamethasone followed by stem cell transplant. Also, targeted therapy can be effectively used before or after a stem cell transplant. However, the decision to undergo a stem cell transplant is com­plex and should be discussed carefully with your doctor.

Research has shown that maintenance therapy (the ongoing use of a drug) with lenalidomide extends patients’ survival time and extends the time they live without active myeloma. However, maintenance therapy has to be used with caution. In addition, many research studies are taking place now to find out more about specific molecular targets and new treatments directed at them.

Often, more than one drug is used
at a time. It may also be recommended to combine chemotherapy with other types of treatment, including targeted therapies or steroids. For instance, the combination of melphalan, the steroid prednisone, and the targeted therapy bort­ezomib is approved by the U.S. Food and Drug Administration for the initial treatment of multiple myeloma because it increases survival when compared with melphalan and prednisone. A person may also be given a combination of melphalan, prednisone, and thalido­mide. Additional combinations of drugs are being evaluated in clinical trials.

The length of chemotherapy treat­ment varies from person to person and is usually given until the myeloma is well controlled.

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Other Drug Therapy
Steroids, such as prednisone and dexamethasone, may be given alone or at the same time as other drug therapy, such as targeted therapy or chemotherapy. For example, lenalid­omide (Revlimid) and dexamethasone as induction and maintenance therapy is recommended for those who are not able to have a stem cell transplantation. In addition, most people with myeloma receive monthly infusions of bisphospho­nate therapy, which are drugs that help to prevent bone disease from myeloma.

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Stem Cell Transplantation
A stem cell transplant is a medical procedure in which bone marrow that contains cancer is replaced by highly specialized cells, called hematopoietic stem cells, that develop into healthy red blood cells, white blood cells, and platelets in the bone marrow. Hematopoietic stem cells are blood-forming cells found both in the bloodstream and in the bone marrow. Today, this procedure is more commonly called a stem cell transplant, rather than bone marrow transplant, because it is the stem cells in the blood that are typi­cally being transplanted, not the actual bone marrow tissue.

There are two types of stem cell transplantation: allogeneic (ALLO)
and autologous (AUTO). ALLO uses donated stem cells, while AUTO
uses the patient’s own stem cells. For multiple myeloma, AUTO is more commonly used. ALLO is being stud­ied in clinical trials.

In both types, the goal is to destroy all of the cancer cells in the marrow, blood, and other parts of the body using high doses of chemotherapy and/or
radiation therapy and then allow replace­ment blood stem cells to create healthy bone marrow.

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Radiation Therapy
Doctors may
recommend radiation therapy for people with bone pain when chemotherapy is not effective or as a way to control pain. However, the use of radiation therapy should be a careful decision. In many instances, pain (especially back pain)
is due to structural damage to the bone. Radiation therapy will not help this type of pain and may compromise the bone marrow’s response to future treatment.

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Surgery
While not a disease-directed treatment option for multiple myeloma, surgery may be used to relieve symptoms.

Getting Care for Symptoms and Side Effects
Cancer and its treatment often cause symptoms and side effects. In addition to treatment to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a per­son’s symptoms and side effects. This approach is called palliative or support­ive care, and it includes supporting a person’s physical, emotional, and social needs. Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional support, and other therapies.

You may also receive palliative treat­ments similar to those meant to eliminate the cancer, such as chemotherapy, sur­gery, or radiation therapy. For example, surgery may be used to relieve pressure from a plasmacytoma on the spine or other organs. More recently, procedures such as kyphoplasty and vertebroplasty have been considered to relieve pain, restore lost height due to collapsing vertebra, and strengthen the spine.

Before treatment begins, talk with your healthcare team about the possible side effects of your specific treatment plan and palliative care options. And during and after treatment, be sure to tell your doctor or another healthcare team member if you are experiencing
a problem so it can be addressed as quickly as possible.

Refractory Myeloma
If your myeloma no longer responds to treatment, this is called refractory myeloma. People with this diagnosis are encouraged to talk with doctors who are experienced in treating this stage of cancer because there can be different opinions about the best treatment plan. You may also want to get a second opinion before starting treatment so you are comfort­able with the treatment plan chosen. For people with refractory myeloma, palliative care to reduce symptoms and side effects is also very important.

Remission and the Chance of
Recurrence
A remission is when
cancer cannot be detected in the body and there are no symptoms. A remis­sion may be temporary or permanent. This uncertainty causes many people
to worry that the cancer will come back. While many remissions are permanent, it’s important to talk with your doctor about the possibility of the cancer re­turning. Understanding your risk of recurrence and the treatment options may help you feel more prepared if
the cancer does return.

If the cancer does return after the original treatment, it is called recurrent myeloma or relapsed myeloma. When this happens, a cycle of testing will be­gin again to learn as much as possible about the recurrence. After testing
is done, you and your doctor will
talk about your treatment options.
Often, the treatment plan will include the treatments described above
(such as targeted therapy and chemo­therapy), but they may be used in a different combination or given at
a different pace.

Your doctor may also suggest
clinical trials that are studying new ways to treat recurrent/relapsed
myeloma. There are several drugs
currently being researched in the late stages of clinical trials that have
shown promise as treatments for
recurrent myeloma. Whichever treat­ment plan you choose, palliative
care will be important for relieving symptoms and side effects.

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This article is based on content from
Cancer.Net®. Copyright 2015. All rights reserved.

This article was printed from copingmag.com and was originally published in Coping® with Cancer magazine,
September/October
2015.

Coping® does not endorse or recommend any particular treatment protocol for readers, and this article does not necessarily include information on all available treatments. Articles are written to enlighten and motivate readers to discuss the issues with their physicians. Coping believes readers should determine the best treatment protocol based on physicians’ recommendations and their own needs, assessments and desires.